Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you rely on urinalysis testing for microscopic hematuria as a means to assess for a ureteral stone for patients with recurrent nephrolithiasis who report mild potential stone-related pain?
I agree with answers posted already. Hematuria is not specific to a ureteral stone location.
What is your approach to the treatment of class IV lupus nephritis for a patient with AKI requiring dialysis?
To manage this patient's class IV lupus nephritis with dialysis-dependent AKI, I will initiate an aggressive induction regimen consisting of pulse IV methylprednisolone (500 to 1000 mg daily for 3 days) followed by an oral prednisone taper, combined with high-dose IV cyclophosphamide (NIH regimen) d...
What is your preferred SGLT2 inhibitor when treating patients with CKD for whom there are no coverage barriers?
I consider them equivalent. Based on insurance coverage, most of my patients are on empagliflozin, followed by dapagliflozin. I rarely use other SGLT-2 inhibitors.
How do you approach the use of ultrafiltration during dialysis sessions in a pregnant patient who was recently started on hemodialysis?
At my university, pregnant patients on dialysis are on fetal monitoring throughout the dialysis session to monitor for fetal distress. Our patients receive 4 hours of dialysis 6 days a week. These patients often have some renal function, as they are not uncommonly initiated on dialysis at GFR > 1...
Do you recommend gradual initiation of dialysis or conventional initiation of dialysis for pregnant patients with worsening renal function who require dialysis?
The reason for gradual initiation of HD is to avoid dialysis disequilibrium, which is more likely to occur at higher levels of uremic toxins and chronic brain responses to chronic high osmotic loads. Initiation of HD in pregnant patients often occurs at GFR levels that are much higher than those use...
How would you advise a CKD patient who asks about oral NSAIDs for management of chronic pain if they have a contraindication to taking acetaminophen?
This depends on the severity of the CKD/eGFR, age, course of disease, available alternatives to NSAIDs, severity of pain and impact on QoL, frequency with which NSAIDs might be taken. I have advised patients whose QoL is adversely affected by pain to take occasionally if needed but to keep to minimu...
How do you balance the risks and benefits of stimulant treatment in patients with poorly controlled hypertension?
The short answer is that there are no clear cutoffs to clearly guide management, and often decisions are guided by shared decision making with patients and relevant specialties (psychiatry, primary care, cardiology).Clinical factors which may prompt you to stop or reduce stimulants: Elevated BP that...
What are some practical tips in distinguishing between metabolic bone disease due to chronic kidney disease and osteoporosis?
The biggest difference between osteoporosis and CKD-MBD has to do with the underlying bone mineral laboratories. Generally, with osteoporosis, bone chemistries are relatively normal; there may be a decrease in Vit D. However, with CKD-MBD, there is usually an increase in PTH, potentially abnormaliti...
Is there a role for 24 hour urine stone risk profiles in your patients with known recurrent struvite kidney stones?
It depends. Pure struvite stones are not a metabolic abnormality; they are the consequence of a urease-producing urinary infection that splits urea to ammonium, raising the urine pH into the high 7-8 range, which in turn precipitates magnesium ammonium phosphate, otherwise known as struvite. Pure st...
Do you avoid potassium citrate in patients with recurrent nephrolithiasis and hypocitraturia if they also take antihistamine medications?
I know of no data showing effects of antihistamine meds on urine citrate or on the effects of potassium citrate on urine citrate. I made a Perplexity search which also found no evidence - this is not a topic I have personally researched because I have never encountered clinical issues about it. So -...